coding chapter 1-4

with

"with mention of" ," associated with" , and " in" indicate that both elements in the title must be present in the diagnostic or procedural statement.

Coding certification is offered by the following professional organization

AHIMA

Which of the following is NOT a coding credential

AHIMA

AHIMA

American Health Information Association

AHA

American hospital association

when translating a disease or a procedure to an ICD-9-CM code, one must have knowledge of

Anatomy, Terminology, Coding rules and guidelines

DS

Data system, sheet

DHHS

Department of health and human services

DRGs

Diagnosis related groups

HIPAAk

Health Insurance Portability and Accountability Act

The current coding system used in the US is known as

ICD-9-CM International classification of diseases, 9th revision, clinical modification codes

WHO

International classification of causes of death World Health Organization

nonessential modifier

Is a term that is enclosed in parenthesis following a main term or a subterm, whose presence or absence has no effect on the code assignment

cooperating parties

NCHS,CMS- federal organization AHA, AHIMA - professional organizations

Symptom

Subjective evidence of a disease or of a patients condition as perceived by the patient

TJC

The joint commission

TPR

Third party reimbursement

What appendix is a complete listing of all three-digit code categories in ICD-9-CM

V-codes

Only A and B are used

Which of the code book volumes are used in a physician's office

see category

a cross-reference that gives directions to go to a specific code category in the tabular list, Volume 1

provider

a physician or any qualified health care practitioner (such as a nurse practitioner or physician assistant

Acute

a short and relatively severe course

neoplasm

abnormal growth

coding conventions

addressed by the ICD-9-CM official guidelines for coding and reporting

compliance

adhering to accepted standards

"code, if applicable, any causal condition"

an instruction an instruction to code the causal condition if it is known

other codes

are used when the information in the medical record provides detail for which a specific code does not exist

ICD-9-CM may be updated

biannually

discharge summary

brief report written by a healthcare provider that summarizes a patients hospital stay

CMS

centers for medicare and medicaid services

CCS

certified code specialist

ICD-9-CM, Appendix D

classification of industrial accidents according to agency contains a complete list of all the three digit code categories

specificity

coding to the highest level of detail

CBC

complete blood count

CC

complication or cormobidity- chief complaint admission note

encoder

computer software to assist in code selection and MS-DRG

When a compliance plan for coding is constructed, the following steps are crucial

conduct audits, develop coding policies and procedures, cultivate a relationship with billing dept,

CEUs

continuing education units

CPT

current procedural terminology

DOB

date of birth

Credential

degree, certificate, or award that recognizes a course of study taken in a specific field

etiology

describes the cause or origin of a disease or condition

Eponym

diagnosis or procedure named for a person

procedure

diagnostic or therapeutic process performed on a patient

ER

emergency room

Integral

essential part of a disease process

Abstracting

extracting data from the health record

brackets

form of punctuation; are used in the index to identify manifestation codes in the alphabetic index

conventions

general rules for the use of the ICD-9-CM classification that must be followed for accurate coding

classification

grouping together, as with items for storage and retrieval

consultant

healthcare provider who is asked to see the patient and provide expert opinion

HPI

history of present illness

HAC

hospital acquired conditions

diagnosis

identification of disease by signs, symptoms, or tests

alphabetic index

index of disease conditions listed in alphabetic order

see and see also

instruction following a main term in the index indicates that another term should be referenced. It is necessary to go to the main term referenced with "See" note to locate the correct code

parentheses

is (are) used in both the index and tabular list to enclose supplementary words that may be present or absent in the statement of a disease or procedure, without affecting the code assignment

see condition

is a reference that instructs coders to look up another term to locate a code for a particular condition. is used in the alphabetic index to provide guidance when two conditions are related or have a causal relationship

principal diagnosis

is defined as the condition established after study to be chiefly responsible for admission of the patient to the hospital

UHDDS

is used for reporting inpatient data in acute care, short term care, and long term care hospitals. developed in 1985. Condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care

MRI

magnetic resonance imaging

MRN

medical record number

coded data are not used for the following reason

medical terminology

MS-DRG

medicare severity adjusted diagnosis-related groups

subterm

modifier of a main term

NCHS

national center for health statistics

NEC

not elsewhere classified- when a specific code is not available for a condition in the index or tabular list for the coder to code "other specified"

NOS

not otherwise specified

OIG

office of inspector general

OGCR

official guidelines for coding and reporting

OR

operating room-operative report

disposition

place a patient goes upon discharge from the hospital

Cormobidity

preexisting secondary diagnosis

POA

present on admission

POA indicator

present on admission indicator; a data element that applies to diagnosis codes for claims involving inpatient care

why is it important for the coder to understand coding convention?

proper conventions will lead to efficient and accurate coding and sequencing

review of systems

question and answer period between healthcare provider and patient regarding healthcare issues

RHIA

registered health information administrators

and

should be interpreted to mean either "and" or "or" when it appears in the title

coding clinic articles

some books are updated with replacement pages quarterly and may include references

SOAP

subjective objective assessment plan

essential modifier

subterms used in the alphabetic index that affect code assignment

manifestation

symptom or condition that is the result of a disease

nomenclature

system of names used as preferred terminology

Main term

term used to identify a disease condition or injury

inclusion terms

terms may be included under certain four and five digit codes; conditions for which that code number is to be used; inclusion terms are not necessarily exhaustive.

diabetes mellitus

the most commonly used etiology/manifestation combinations are the codes

instructional notes

these include general notes, inclusion, and exclusion notes, code first notes, and use additional code notes.

the purpose of a classification system is

to group like items for storage and retrieval

excludes note

under a code indicates that the terms excluded from the code are to be coded elsewhere

parenthesis ( )

used both in the index and tabular list to enclose supplementary words that may be present or absent in the statement of a disease or produce without affecting the code number to which it was assigned

colons

used in both inclusion and exclusion notes to indicate that one of the modifiers from the list indented below the entry must be present in order for the statement to apply

due to

used in the alphabetic index is sequenced immediately following the main term, not in alphabetical order

brackets [ ]

used in the tabular list to enclose synonyms, alternative wording, or explanatory phrases

unspecified codes

usually a code with a four digit or fifth digit "0" for diagnosis that is used when the information in the medical record is insufficient to assign a more specific code

which volume of the ICD-9-CM book contains the alphabetic index of diseases and injuries?

volume 2

asymptomatic

without any symptoms

terminology

words or phrases that apply to a particular field

connecting words

words such as "with" "in" "due to" and "associated with" are used to express the relationship between the main term or a subterm indicating an associated condition of etiology

Documentation

written or typed information supplied by the healthcare provider to communicate patient data and activity